Thanks to Migrant Clinics Network , Institute for Health Care Improvement, Marc Williams- Intermountain Healthcare &

Mike Hindmarsh

MacColl Institute for Health Care Innovation

Institute For Healthcare Improvement

Paul Bray, MA, LMFT

Assistant Research Professor, Dept. of Family Medicine, ECU

Work e-mail pbray@pcmh.com

Need for Quality, Introduction to Quality Improvement and PCMH

Why are we discussing improving quality in health

care? It is the center of discussion with health

care reform: All reform emphasis quality

It’s on your certification exams: Specialty board certification & JCAHO (Joint Commission on Accreditation of Health Care Organizations) accreditation

It can increase your pay: Incentive pay, managed care pay, patient centered medical home and Pay for performance

It can keep you competitive: Learn about quality improvement because it is a world wide movement

Most important, for your patients: Learn about the methods to help your patients

The IOM Quality Report- To Err Is Human: Building a Safer Health System

Do we have a qualityProblem in US health care?

Consensus: We do nothave a problem we have a CRISIS!

To Err is Human Medical Injuries IOM November 1999 Report

44,000-98,000 deaths per year through medical errors More people die from medicalerrors than from breast cancer orAIDS or motor vehicle accidents 100,000 deaths per year from procedures/surgery complications, exceeding motor vchicle deaths Direct health care costs $9-15billion/year It’s a conservative estimate!!

March 1, 2001

“Between the healthcare we have and thecare we could havelies not just a gap,but a chasm.”

The IOM Quality Report- Update 2001

How Good Are We? Only 50% of Americans receive recommended preventive care

Patients with acute illness 70% received recommended treatments 30% received contraindicated treatments

Patients with chronic illness 60% received recommended treatments 20% received contraindicated treatments

Schuster et al. How good is the quality of healthcare inthe United States? Milbank Quarterly 76:517-63, 1998

The toll on patients is high: US Data

Source: Elizabeth McGlynn, et al. “The Quality of Health Care Delivered to Adults in the US.” NEJM 2003; 348:2635-45

CONDITIONSHORTFALL IN CARE

AVOIDABLE TOLL

Diabetes

Hypertension

Heart attack

Pneumonia

Colorectal cancer

Average blood sugar not measured for 24% 29,000 kidney failures - 2,600 blind

Less than 65% received indicated care - 68,000 deaths

39% to 55% didn't receive needed medications - 37,000 deaths

36% of elderly didn't receive vaccine - 10,000 deaths

62% not screened - 9,600 deaths

Source: World Bank’s World Development Indicators, UC Atlas

"THIS WEEK I CONVEYED TO CONGRESS MY BELIEF THAT ANY HEALTH CARE REFORM MUST BE BUILT AROUND FUNDAMENTAL REFORMS THAT LOWER COSTS, IMPROVE QUALITY AND COVERAGE, AND ALSO PROTECT CONSUMER CHOICE," BARACK OBAMA JUNE 6, 2009

The IOM Quality report: A New Health System for the 21st Century

Institute of Medicine

“The current care

systems cannot do the job.”

“Trying harder will not work.”

“Changing care systems will.”

http://www.iom.edu/CMS/8089.aspx

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model or Planned Care Model

The  patient‐centered  medical  home  is  a  model  for  care  provided  by  physicians  practices  that  seeks  to  strengthen  the  physician‐patient  relationship  by  replacing  episodic  care  based  on  illnesses  and  patient  complaints  with  coordinated  care  and  a  long‐term  healing  relationship.  

Primary Care as the key to Quality:Patient-Centered Medical Home

(PCMH)

Reimbursement is central to PCMH and Quality ImprovementReform Proposal: fees + PCMH pay-per-patient + performance from system of quality

1. Team based care2. Whole person orientation3. Care coordination4. Enhanced access5. Systems for quality6. Systems for safety

Characteristics of PCMH(National Center for Quality Assurance)

•   24/7 Access  and  Communication  

•   Patient  Tracking  and  Registry   Functions  

•   Care  Management from a nurse or other non-physician  

•   Patient  Self‐Management  Support  •   Electronic  Prescribing  

•   Test  Tracking  

•   Referral  Tracking  

•   Performance  Reporting  and     Improvement, team reviews results  

•   Advanced  Electronic  Communications

How do we know a clinic is a PCMH

How do we have “systems of quality”?

(One of the 6 requirements of a PCMH)

Set a goal (if you do not have a target, that is what you will hit)

Form a teamTake Small stepsMeasure your progress- collect data

CORE STEPS IN CONTINUOUS IMPROVEMENT (i.e. diabetes)

Define a clear aim (reduced morbidity from diabetes)

Identify and define measures of success. (>40% < 7 A1c)

Form a team that has knowledge of the system needing improvement (physician, dia. Ed, scheduler)

Brainstorm potential change strategies for producing improvement. (add 20 min ed visit to >7)

Plan, collect, and use data for facilitating effective decision making. (measure A1c for ed vs. non ed)

Apply the scientific method to test and refine changes (id best curriculum & self-management)

What is the PDSA Cycle?

Act• What changes are to be made?

• Next cycle?•maintain modify add to the plan

Plan• Objective• Questions and predictions (why)• Plan to carry out the cycle (who, what, where, when)

Study• Complete the

analysis of the data•Compare data to

predictions•Summarize

what was learned

Do• Carry out the plan• Document problems and unexpected observations• Begin analysis of the data

How do we get there?

1. Define a Problem2. Set a Goal

3. Form a Team4. Plan for a change using “small scale

steps”5. Do the change

6. Study- collect data & analyze change/outcome

7. Act – correct, repeat, spread, install

Achievements In the first Diabetes Collaborative

applying the CCM; enrolling 16,000 people with diabetes.

The national shared performance measure of “two Hemoglobin A1c (HbA1c) tests done within a year” increased by almost 300%.

Diabetes pilot patients had significantly reduced CVD risk (pilot>control), resulting in a reduced risk of 1 cardiovascular disease event for every 48 patients exposed(RAND Corp. Study www.improvingchroniccare.org).

Reading List for Residence First QI Application Session

ECU Getting Started Powerpoint Presentation CQI Family Medicine CQI Introduction Mike Hindmarsh chronic care model intro IHI Improvement Methods Intro Web Sitehttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/ Tools: Cause-effect “Fish-bone” exercisehttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/Cause+and+Effect+Diagram.htm Tools: Pareto Diagram Exercisehttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/Pareto+Diagram.htm

Resourceshttp://www.ihi.org: Institute for Healthcare

Improvement, tools to print , “how to” manuals

http://www.healthdisparities.net: collaboratives done at HRSA clinics, Handbook for many chronic conditions (diabetes, asthma, CHF etc)

http://betterdiabetescare.org: info for practitioners

Resourceshttp://www.Improvingchroniccare.orgEducational materials for patientshttp://www.ncdiabetes.org/http://www.aace.comhttp://ndep.nih/govhttp://www/cdc/gov/team-ndephttp://www.diabetesatwork.org